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Resection of the Sciatic, Peroneal, or Tibial Nerves: Assessment of Functional Status

From the Departments of Surgery (ADB, JSG, DG, MFB) and Orthopedic Surgery (PB, JHH), Memorial Sloan-Kettering Cancer Center, New York, New York; and Antigenics, Inc. (JJL), New York, New York.

Correspondence: Address correspondence and reprint requests to: John Healey, MD, Chief, Orthopedic Surgery, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021; Fax: 212-794-4095; E-mail: healeyj{at}mskcc.org

	ABSTRACT

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Background: Lower-extremity tumors are often treated by amputation rather than limb-sparing excision that sacrifices the sciatic nerve or a branch. This study assessed the functional outcome of major nerve sacrifice during limb-sparing resections for lower-extremity soft tissue sarcoma.

Methods: Patients who underwent division of the sciatic, tibial, or peroneal nerve(s) during limb-sparing sarcoma surgery (January 1982 through June 2000) were identified. Eleven surviving patients evaluated their pre- and postoperative functional status by self-administered questionnaire (six sciatic, two tibial, and three peroneal nerve divisions).

Results: Eighteen patients (10 male, 8 female; 14–84 years old) had nine primary and nine locally recurrent tumors. Tumors were high (16) or low grade (two). Five patients died of disease and two died of other causes. Median overall survival was 50 months. One of 11 reported increased pain. Eight had new phantom sensations with a median intensity of 4.5 (1 = least; 10 = most). All patients used an ankle brace to walk after a sciatic (four) or peroneal (one) division. Walking ability and distance after surgery was unchanged (nine), improved (one), and worsened (one). Standing improved in 7 of 11 patients. Proprioception in the affected extremity was retained in six. The median postoperative leg functional score was 8 (1 = worst; 10 = best). No patient developed foot ulcers. One patient underwent amputation for recurrence. All patients preferred their status over having an amputation.

Conclusions: Objectively and subjectively, division of the major lower-extremity nerves causes acceptable functional deficits in most patients. Resection of affected sciatic nerve (branches) during limb-sparing tumor surgery is an excellent alternative to amputation.

Key Words: Sarcoma • Functional status • Sciatic nerve • Limb-sparing surgery

	INTRODUCTION

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Most authors now agree that the goal of management for patients with soft tissue sarcoma of the extremity is the preservation of a functional limb in light of the evidence that there is no decrease in survival by less radical procedures.¹ The indications for amputation are narrower than ever before, and yet some ambiguity still exists. The sacrifice of complete muscle groups and veins is usually well tolerated. Resection and bypass of the major arteries is technically feasible. Loss of skin and soft tissue is remedied by plastic surgical reconstruction. Even segmental bone or joint resection and replacement can be used to preserve function.² However, involvement of the major motor nerves of the lower extremity is often cited as an indication for amputation.^3,4

There are few reports on the surgical management of patients with major nerve involvement by soft tissue sarcoma,^3–10 and still fewer discuss the functional outcome in patients after resection of these nerves.^11–14 We undertook this study to look at patient characteristics and their perceptions of functional outcome and quality of life after undergoing limb-sparing surgery that included resection of the sciatic, peroneal, or tibial nerve.

	METHODS

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Cases were identified from our prospective database of all patients with soft tissue sarcoma of the extremity treated at Memorial Sloan-Kettering Cancer Center between July 1982 and July 2000. For this functional assessment, we limited eligibility to those patients undergoing resection of the sciatic, tibial, or peroneal nerves.

Case histories were reviewed from presentation through treatment and follow-up. Survival was calculated from the date of surgery in which the nerve was sacrificed. Pathologic variables considered included histological type, size, grade, and margin status. Records were reviewed for the subsequent course, including adjuvant treatment, development of local or distant recurrence, and further surgical procedures.

Surviving patients were contacted by phone and interviewed with a standardized questionnaire consisting of 19 items, most on an analog scale, aimed at determining the patient’s impressions of his or her functional status both before and after the operation. The questionnaire was modeled after the quality of life scale¹⁵ and the amputation scale developed by Wartan et al.¹⁶ Items were grouped into seven categories: ambulation, standing, pain, phantom pain, phantom sensation, global quality of life, and global functional outcome (Table 1). Each item was followed by a 10-point scale ranging from 1 to 10 for functional questions and quality of life; 1 was "worst," and 10 was "excellent." For the pain and phantom sensation items, 1 was "no pain or bad sensation" and 10 was "worst pain or sensation." The pain and phantom sensation scores were then inverted by using a formula (11-score) to make 10 the best possible score for all items. Results of the first five scaled items (ambulation, standing, pain, phantom pain, and phantom sensation) were summed to create a total function/pain score as a measure of quality of life related to the involved limb.

	RESULTS

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Of 1505 patients with soft tissue sarcoma of the lower extremity seen at MSKCC between July of 1982 and November of 2000, we identified 18 patients who had undergone resection of the sciatic,¹² peroneal,³ or tibial nerves.³ The median age at nerve resection operation was 42.5 years (range, 14–84 years). There were 8 women and 10 men in this cohort. Nine patients presented with a primary tumor and nine with recurrent tumors.

The distribution of histopathologic subtypes is listed in Table 2. The most common tumor was malignant fibrous histiocytoma. Malignant peripheral nerve sheath tumors in patients with neurofibromatosis were the second most common. Of note, one patient underwent sciatic nerve resection at re-resection of a desmoid tumor. Only two patients had tumors smaller than 5 cm in diameter, and more than half of the tumors¹⁰ were >10 cm in diameter. Sixteen patients had high-grade tumors. Final pathology confirmed nine patients with nerve invasion and nine patients with nerve encasement without evidence of invasion. At resection two patients were known to have grossly positive margins (one pelvic periosteum and one sciatic nerve root), and an additional two patients were found to have microscopic margin positivity (on soft tissue margin).

Median follow-up was 24 months (range, 5–185 months). At last follow-up, eight patients were free of disease, three were alive with disease, five were dead of disease, and two were dead of unknown causes (one at 5 and one at 15 years postresection). The 2-year disease-free survival was 48%, and the overall survival was 77% at 2 years.

A total of 11 patients were able to complete all or part of the survey. One patient was lost to follow-up 15 years posttreatment. The complete results of the surveys are listed in Tables 3–6. No patient reported skin breakdown in the denervated area during follow-up.

Standing
Preoperatively 8 of 11 patients could stand for more than 30 minutes, and this increased to 10 of 11 postresection. Median satisfaction scores were unchanged, at 9.5 (almost completely satisfied), pre- and postoperatively.

Proprioception
All patients reported satisfactory proprioception preoperatively; two patients reported complete loss of this ability postresection.

Pain
Six patients reported significant pain in the affected limb preoperatively; this decreased to four patients postoperatively. Four of six patients who experienced pain preoperatively required pain medicine for control of the pain. For two of these patients the pain was constant. Three of four patients who experienced pain postoperatively required pain medicine for constant pain. The severity of the pain was perceived as more severe preoperatively (median, 3; "some discomfort") as compared with postoperatively (median, 1; "no pain").

Phantom Pain/Sensation
Ten of 11 patients responded to the questions on phantom pain and sensation. Four patients reported pain in the distribution of the involved nerve preoperatively, whereas four patients reported this type of pain postoperatively. The median severity score was unchanged at 1 ("none"). When questioned about electric or cramping sensations in the distribution of the involved nerve, none of the patients reported phantom sensations preoperatively. Postresection, however, 8 of 10 patients reported this kind of sensation. The median severity score was 1 (none) preoperatively, and this worsened to 4.5 ("uncomfortable") postoperatively.

Functional Outcome and Global Quality of Life
The median functional outcome score reported by postoperative patients was 9 (excellent). The patients’ perception of their quality of life was a median of 9.5 (excellent) preoperatively and 8.5 postoperatively.

Correlations
The scores for ambulation and standing were added to the inverse scores for pain, phantom pain, and phantom sensation to obtain total pre- and postoperative function and pain scores for each patient. The preoperative value was subtracted from the postoperative value to obtain a function/pain difference score. A negative score meant a decrease in function or increase in pain, and a positive score indicated postoperative improvement. The mean change was an improvement of 1.3 points with an SE of 4.3. When a similar calculation was used to determine the difference in quality of life score between pre- and postoperative patients, the mean change was .9 with an SE of .9. Both of these calculations indicate an overall improvement in quality of life postoperatively. The function/pain difference score and quality of life difference score displayed a significant correlation for each patient (R = .8, P < .01). The function/pain difference score was inversely correlated with the preoperative quality of life score (R = -.8, P < .005), whereas the quality of life difference score was inversely correlated with preoperative function/pain score (R = .79, P < .01). Overall function score did not correlate with any of the other scales. This survey had no floor effect; Table 5 illustrates that only one patient reported the worst possible score in three of the five preoperative categories. All other patients could have reported lower postoperative function/pain scores. Conversely, there was a ceiling for four patients, who reported the best possible score in all five preoperative categories; these patients could not improve. All patients reported a preference for their current state over an amputation.

	DISCUSSION

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Approximately 1.2% of patients with soft tissue sarcoma of the lower extremity seen by our clinic over the past 18 years have required resection of the sciatic, peroneal, or tibial nerves as a component of limb-preserving resection. The majority of these patients had large, high-grade tumors. The overall survival for these patients was similar to that reported for all large high-grade tumors of the extremity.¹⁷ Of five local recurrences, one patient required amputation for tumor control and infection, and 48% of all patients were tumor free at 2 years. These data illustrate that limb preservation including nerve resection yields acceptable therapeutic results for soft tissue sarcoma.

As Bell et al.¹² and Davis et al.¹³ have pointed out, function is the key to limb preservation. In their studies of patients undergoing limb preservation, three factors are identified as strong predictors of poor functional outcome: tumor size, nerve resection, and complications. Among the functional assessments available after major limb–sparing surgery, the Toronto Extremity Salvage Score (TESS) stands out as a reliable and accurate measure of functional living.¹⁸ This questionnaire lists 30 activities, and the respondent chooses a level of difficulty for each item. The difficulty ranges from impossible to not difficult at all. In a comparative study evaluating the TESS, all of the functional assessment scores tested did correlate with quality of life and with each other.¹⁹ Incidentally, quality of life in that study, as measured by the Short Form-36 (SF-36),¹⁵ was affected only by age and prior surgery and not by tumor size or extent of surgery. There are other surveys available for limb function postresection.^18,20 In addition, energy expenditure, gait analysis, and strength can be tested clinically.²¹ All of these evaluations may be more productive if performed prospectively and compared over time.

In a recent multicenter retrospective analysis of patients undergoing sciatic nerve resection, Fuchs et al.¹¹ used the TESS as a measure of clinical outcome. In that study, which was limited to thigh tumors involving both divisions of the sciatic nerve, 10 patients had a mean overall score of 74%, indicating a high level of functional ability postoperatively. Of note, 1 patient in the cohort of 20 patients who had a sciatic nerve resection developed a foot ulcer and ultimately required an amputation for wound management. The authors conclude that patients reported a high level of function but need to be informed ahead of time about the disability that will result from limb preservation.

Our purpose in this study was to further evaluate functional outcome in this high-risk group. The questionnaire was developed to touch on key aspects of limb function and to evaluate pain and phantom sensations. Specifically, we wanted to address preoperative dysfunction or pain and compare it with the postoperative state. We used an analog scale similar to the Short Form-36 for satisfaction, quality, or pain severity. In addition, we modeled our questions about phantom pain after the amputee survey developed by Wartan et al.¹⁶ The patients contacted for this survey all spoke English, all agreed to participate, and 10 of 11 patients answered all items requested, a rare level of compliance for similar surveys in the literature.

The majority of extremity soft tissue sarcomas arise in the proximal thigh,²² and therefore branches of the femoral nerve and their target muscles are often sacrificed. This heterogeneity of muscle loss with or without nerve resection is difficult to characterize retrospectively. Therefore, we limited this study to include only resection of the sciatic, peroneal, or tibial nerves to keep the functional assessment more uniform.

Our survey results indicated that most patients had minimal change in ability to walk or stand postoperatively. Fewer patients complained of pain postoperatively, and the pain severity was decreased for most patients. Of note, phantom sensations were reported by a majority of the patients postoperatively with a significant severity. This is not surprising given the high percentage of patients with pain and nerve dysfunction preoperatively. These results correspond to similar data collected in patients undergoing amputation. The mean difference in function/pain score was slightly improved postoperatively, and there was a slight improvement of quality of life score. Both of these scores were inversely correlated with preoperative quality of life and preoperative function/pain score. That indicates that the patients with worse function or pain preoperatively had more room to improve, whereas those starting without disability could not get any better and in fact could only get worse or stay the same. The important conclusion from the survey is that these patients did not perceive themselves as disabled or poorly functioning.

The literature regarding management of tumors involving the major lower extremity nerves includes a case report of sciatic nerve resection¹⁰ and an amputation for tibial and peroneal involvement by tumor.³ There are three series of leg tumors requiring peroneal nerve resection, with two recommending resection when indicated^9,14 and the third recommending resection and nerve graft,⁶ although function returned in only one of five patients grafted. Ozaki et al.¹⁴ reported a series of 10 patients in whom peroneal nerve resections were not reconstructed, all of whom returned to the preoperative level of function with a leg brace. There are two large series of neurogenic tumors involving the sciatic nerve: Thomas et al.⁴ and Kim and Kline⁶ recommend early amputation for high-grade neurofibrosarcomas, whereas Hruban et al.⁵ practiced limb preservation in most patients. More recently, Lee et al.⁷ recommended sciatic nerve resection and grafting for tumors involving the sciatic nerve. In the recent report by Fuchs et al.,¹¹ nerve grafting was not recommended. In our experience, the length of nerve resection commonly precludes grafting. Sciatic nerve grafting is also a problem because the grafts often fail to match the corresponding fascicles within the large sciatic nerve bundle. Furthermore, in older patients and in patients with radiated tissue, nerve regeneration is not dependable after grafting.

Our approach to the management of patients having major nerve resection is straightforward and related to the disability generated. The preoperative imaging helps guide our surgical plan.²³ Of course, the patient must be made aware of the consequences of the planned nerve resection to help make the decision.²⁴ A sciatic nerve resection yields a balanced flail foot, with some proprioception carried by the saphenous branch of the femoral nerve. There is no fixed equinnus deformity, but conversely there is no ability to push off by using the ankle extensors. These patients are managed with a static ankle brace. For some, boots or high-top sneakers are adequate. Patients undergoing resection of the peroneal nerve will have a foot drop, and a dynamic brace helps return the foot to a neutral position during ambulation. Some of these patients prefer a rigid brace for cosmetic reasons. Patients undergoing tibial nerve resection below the innervation to the ankle extensors may require just an arch support without a brace. In those who lose this innervation, a calcaneal gait with poor push-off develops. Occasionally these patients need a rigid ankle brace or even ankle fusion. All patients are enrolled in a rehabilitation program, educated about nail care, instructed to place impact-reducing gel pads in their shoes, and told to routinely examine their insensate regions for skin breakdown.

We have demonstrated that limb preservation with major nerve resection is not associated with a significant increase in dysfunction or pain. We believe that isolated nerve involvement is not an indication for amputation and that nerve resection is an acceptable alternative when indicated.²⁴ These patients must be counseled about the expected neurological deficits and phantom sensation that may develop, as well as the appropriate precautions for adequate return to daily function.

	Acknowledgments

 
Supported in part by the Gorin Foundation at Memorial Sloan-Kettering Cancer Center and National Institutes of Health Grant P01-CA47179.

	Footnotes

 
Presented at the 54th Annual Cancer Symposium of the Society of Surgical Oncology, Washington, DC, March 17, 2001.

Received for publication March 16, 2001. Accepted for publication August 6, 2001.

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